What is the initial management for a patient with a sternal fracture?

Initial Management of Sternal Fractures

The initial management of a patient with a sternal fracture should prioritize adequate pain relief using multimodal analgesia, including regular paracetamol (acetaminophen) and cautious use of opioids, while avoiding NSAIDs due to their contraindication in trauma patients. 1

Pain Management Protocol

• Provide appropriate pain management immediately before starting diagnostic investigations 1
• Implement multimodal analgesia:
  • Regular paracetamol (acetaminophen) unless contraindicated
  • Cautious use of opioids after reviewing renal function (approximately 40% of trauma patients have renal dysfunction) 1
  • Consider nerve blocks for effective pain control 1
  • Avoid NSAIDs due to relative contraindication in trauma patients 1

Diagnostic Evaluation

• CT scan of the chest is the preferred initial imaging modality 1
• Evaluate for associated injuries, as sternal fractures are often accompanied by other thoracic injuries 2
• Cardiac assessment:
  • Monitor for arrhythmias (occur in approximately 6% of patients) 1
  • ECG and cardiac troponins should be obtained
  • Echocardiography is not routinely recommended for isolated sternal fractures with normal ECG and cardiac troponins 1

Determining Need for Hospitalization

Most sternal fractures can be managed conservatively 3, and routine admission for isolated sternal fractures is often unnecessary 4. Consider hospitalization for:

• High-impact trauma
• Severely displaced fractures
• Significant associated injuries
• Complex analgesic requirements
• Important co-morbidities
• Inadequate domestic support 5

Surgical vs. Conservative Management

Most sternal fractures are treated conservatively, but surgical fixation should be considered in:

• Cases of severe pain
• Respiratory failure or dependency on mechanical ventilation
• Cosmetic deformity
• Malunion or nonunion
• Compression of the heart 3
• Unstable fractures with severe displacement 2

Follow-up Care

• Initial follow-up within 1-2 weeks of discharge
• Clinic follow-up within 2-3 weeks to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Common Pitfalls and Caveats

1. Failing to assess for associated injuries: Sternal fractures may indicate high-energy trauma with potential for other significant injuries 2
2. Overlooking renal dysfunction when prescribing pain medications: Approximately 40% of trauma patients have renal dysfunction 1
3. Routine hospitalization of all patients with isolated sternal fractures: Evidence suggests this is unnecessary in many cases 4, 5
4. Neglecting to monitor for cardiac complications: Although rare in isolated fractures, cardiac monitoring is important initially 1